Hindawi Publishing Corporation
International Journal of Dentistry
Volume 2012, Article ID 365809, 5 pages
doi:10.1155/2012/365809
Research Article
Prevention and Treatment of Postoperative Infections after Sinus
Elevation Surgery: Clinical Consensus and Recommendations
Tiziano Testori,1 Lorenzo Drago,2 Steven S. Wallace,3 Matteo Capelli,1 Fabio Galli,1
Francesco Zuffetti,1 Andrea Parenti,1 Matteo Deflorian,1 Luca Fumagalli,1
Roberto L. Weinstein,4 Carlo Maiorana,5 Danilo Di Stefano,6 Pascal Valentini,7
Aldo B. Giannı̀,8 Matteo Chiapasco,9 Raffaele Vinci,10 Lorenzo Pignataro,11
Mario Mantovani,11 Sara Torretta,11 Carlotta Pipolo,12 Giovanni Felisati,12
Giovanni Padoan,13 Paolo Castelnuovo,13 Roberto Mattina,14 and Massimo Del Fabbro15
1 Section
of Implant Dentistry and Oral Rehabilitation, Department of Biomedical, Surgical and Dental Science, School of Dentistry,
I.R.C.C.S. Galeazzi Institute, University of Milan, Via Riccardo Galeazzi 4, 20161 Milan, Italy
2 Laboratory of Clinical Chemistry and Microbiology, I.R.C.C.S. Galeazzi Institute, University of Milan, Milan, Italy
3 Department of Implantology, Columbia University, New York, NY, USA
4 Department of Biomedical, Surgical and Dental Science, School of Dentistry, I.R.C.C.S. Galeazzi Institute,
University of Milan, Milan, Italy
5 Department of Oral Surgery, Dental Clinic, School of Dentistry, Istituti Clinici di Perfezionamento (ICP),
University of Milan, Milan, Italy
6 Oral Surgery, Department of Oral Science, University Vita-San Raffaele Salute, Milan, Italy
7 Department of Oral Implantology, University of Corsica Pasquale Paoli, Corte, France
8 Department of Maxillofacial Surgery, University of Milan and Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico,
Milan, Italy
9 Department of Oral Surgery, School of Dental Medicine, Department of Medicine, Surgery and Dentistry, San Paolo Hospital,
University of Milan, Milan, Italy
10 Division of Advanced Oral Surgery, Department of Dental Medicine, University Vita-Salute, San Raffaele, Milan, Italy
11 Otorhinolaryngology Clinic, Department of Otorhinolaryngoiatric Sciences, Fondazione IRCCS Cà Granda,
Ospedale Maggiore Policlinico, Milan, Italy
12 Head and Neck Department, San Paolo Hospital, University of Milan, Milan, Italy
13 Department of Surgical Sciences, University of Insubria, Varese, Italy
14 Department of Public Health, Microbiology and Virology, University of Milan, Milan, Italy
15 Section of Oral Physiology, Department of Biomedical, Surgical and Dental Science, I.R.C.C.S. Galeazzi Institute,
University of Milan, Milan, Italy
Correspondence should be addressed to Tiziano Testori, [email protected]
Received 7 May 2012; Accepted 6 June 2012
Academic Editor: Silvio Taschieri
Copyright © 2012 Tiziano Testori et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Introduction. Maxillary sinus surgery is a reliable and predictable treatment option for the prosthetic rehabilitation of the atrophic
maxilla. Nevertheless, these interventions are not riskless of postoperative complications with respect to implant positioning in
pristine bone. Aim. The aim of this paper is to report the results of a clinical consensus of experts (periodontists, implantologists,
maxillofacial surgeons, ENT, and microbiology specialists) on several clinical questions and to give clinical recommendations
on how to prevent, diagnose, and treat postoperative infections. Materials and Methods. A panel of experts in different fields
of dentistry and medicine, after having reviewed the available literature on the topic and taking into account their longstanding clinical experience, gave their response to a series of clinical questions and reached a consensus. Results and Conclusion.
The incidence of postop infections is relatively low (2%–5.6%). A multidisciplinary approach is advisable. A list of clinical
recommendation are given.
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1. Introduction
Maxillary sinus surgery can be defined as a routine and predictable procedure for the prosthetic rehabilitation in the
atrophic maxilla [1–7].
In the past, implant treatment was applied to total
edentulous patients [8, 9] and was later extended to partially
edentulous patients; however, the resorption of the alveolar
ridges in the maxilla often limits the available bone for positioning dental implants unless a reconstructive phase was
performed and different classifications of bone atrophy and
relative treatments protocols were proposed [10–12].
Management of patients undergoing sinus lift procedure
often requires an interdisciplinary approach involving various specialists in the presurgical phase to optimize surgical
results and reduce complications [13–15].
There are anatomic alterations and pathological conditions such as inflammatory-infective processes or sinus manifestations of systemic or cancer related diseases that represent contraindications and should be treated prior to maxillary sinus elevation [16, 17].
Complications are infrequent and can be easier managed
if promptly diagnosed.
Postoperative infections are relatively infrequent, with
infection rates reported between 2% and 5.6%, with no distinction being made between true sinus and sinus graft
infections.
Infections after sinus elevation surgery can occur in two
locations. Most commonly the infection is not a true sinus
infection but an infected sinus graft. It should be realized that
the sinus graft is not actually in the sinus but is located below
the elevated sinus membrane, hence the term subantral
augmentation. True sinus infections are less common but
may have more widespread consequences such as a pansinusitis which can occur as a result of the interconnectivity
of the sinus network [18–22].
The aim of this paper is to report the results of a
clinical consensus of experts (periodontists, implantologist,
maxillofacial surgeons, ENT, and microbiology specialists)
on several clinical questions and to give clinical recommendations on how to prevent, diagnose and treat postoperative
infections.
The clinical questions addressed by the panel of experts
are as follows.
(1) What is the normal postoperative patient response to
sinus surgery?
(2) What is the correct preop and postop pharmacological treatment after sinus surgery?
(6) What are the clinical indications for a microbiologic
assay?
(7) In case of surgical management of postoperative
infections, is a reentry possible and how long should
the surgeon wait?
(8) What are the most appropriate clinical recommendations to reduce the incidence of postop complications?
2. Materials and Methods
A panel of experts in different fields of dentistry and medicine like periodontists, implantologists, maxillofacial surgeons, ENT, and microbiology specialists after having reviewed the available literature on the topic and taking into
account their long standing clinical experience gave their
response to the above mentioned questions and reached a
clinical consensus.
3. Results
(1) What Is the Normal Postoperative Patient Response to Sinus
Surgery? A normal postoperative patient’s response could be
swelling, ecchymosis, and mild-to-moderate discomfort that
is rarely spontaneous within the first few days and usually
resolves within three weeks. Minor nose bleed might be
present.
The resolution of symptoms after three weeks suggest
a normal postop period. Usually acute spontaneous pain is
absent; however, if present it is a warning sign for the clinician to investigate promptly.
(2) What Is the Correct Preop and Postop Pharmacological
Treatment after Sinus Surgery? Usually sinus surgery is a surgical procedure carried out under antibiotic prophylaxis
and postoperative drug therapy as seen in Table 1. This
pharmacological regimen is based on clinical experience and
indirect evidence. In implant dentistry, there is a trend that
favor the use of prophylactic antibiotics to reduce infections
[23, 24].
With regard to preop or postoperative corticosteroid
therapy, a common consensus was reached regarding the use
of corticosteroid but not on the dosage due to the heterogeneity of the pharmacological regimens utilized by the different experts.
(4) What is the difference between early and delayed
complication?
(3) In Case of Persistence of Signs and Symptoms beyond 3
Weeks, What Are the Proper Clinical Recommendations? The
presence of signs and symptoms beyond three weeks calls for
a careful examination and monitoring of the patient until
total recovery.
If the patient has not fully recovered after 3 weeks, CT
is suggested to evaluate maxillary sinuses, nasal, and sinus
endoscopy can be added if necessary.
(5) (a) Which postop infections can be managed only
with pharmacological treatment? (b) Which postop
infections require a combined pharmacological and
surgical approach?
(4) What Is the Difference between Early and Delayed Complication? Early complication happens within 21 days following surgery.
(3) In case of persistence of signs and symptoms beyond
3 weeks, what are the proper clinical recommendations?
International Journal of Dentistry
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Table 1: Prophylaxis and post-operative drug therapy in sinus lift patient.
Prophylaxis
Post-operative therapy
Patient not allergic to penicillin
Amoxicillin/clavulanic acid 1 gr twice a day (BID)
per os starting 24 hours before surgery
Amoxicillin/clavulanic acid 1 gr three times a day
(TID) per os for 7 days
Patient allergic to penicillin
Clarithromicin 250 mg BID + Metronidazole 500
TID per os starting 24 hours before surgery
Clarithromicin 250 mg BID + Metronidazole 500
TID per os for 7 days
Table 2: Drug therapy for sinus lift complications.
Amoxicillin/clavulanic acid 1 gr
TID and Metronidazole 500 mg
TID per os
Levofloxacin 400 mg BID per os
Patient allergic to penicillin
until 72 hours to symptom
remission
Usually these regimens are utilized for 7–10 days
Patient not allergic to penicillin
Delayed complication sets in more than 21 days after the
surgery.
A clear distinction between early and delayed complications allows a time-related assessment of the complication.
This classification is useful in communicating among clinicians and writing scientific papers.
(5a) Which Postop Infection Can Be Managed Only with Pharmacological Treatment? Graft infection well contained under
the sinus membrane, as seen in the scan, with only a clean
serum exudate from the surgical incision can be managed
only with pharmacological treatment (Table 2).
A strict monitoring of the patient is needed until
resolution of the complication.
(5b) Which Postop Infection Require a Combined Pharmacological and Surgical Approach? If the graft is well contained
under the schneiderian membrane (as seen in the CT
scans) but signs and symptoms still persist beyond 3 weeks
associated with additional symptoms (like tenderness, nasal
obstruction, pain, fistulization, purulent discharge from the
nose and throat, flap dehiscence, and suppuration), partial
or total removal of the bone graft by oral access combined to
pharmacological therapy is recommended.
If the graft is not contained under the sinus membrane
and a loss of graft material inside the sinus is present (as seen
in the CT scans) a multidisciplinary approach to manage
the complication is mandatory. Functional endoscopic sinus
surgery (FESS) could be suggested along with the removal of
bone graft and dental implants from an oral approach [25].
A quick and multidisciplinary approach to the patient
with sinus complications is required in these clinical scenarios.
(6) What Are the Clinical Indications for a Microbiologic Assay?
Microbiologic assay is always suggested but a negative result
(bacteria absence) does not mean absence of infection. Usually during antibiotic therapy, bacterial cultures are negative.
If possible it is recommended to make a second test some
days after the end of the pharmacological therapy.
The indications to request a microbiologic assay have to
be evaluated in relation to the antibiotic response in term of
days versus recovery speed, seriousness of the complication,
and general patient condition. A close patient monitoring is
always advised.
(7) In Case of Surgical Management of a Postoperative Infection, Is a Reentry Possible and How Long Should the Surgeon
Wait? A sinus reentry is possible after a CT evaluation and
preferably an ENT reevaluation to confirm a complete sinus
healing (which on the average requires 6–9 months).
(8) What Are the Most Appropriate Clinical Recommendations
to Reduce the Incidence of Postop Complications? The clinical
recommendation are as follows:
(i) careful assessment of the medical history of the patient,
(ii) proper patient selection with healthy maxillary sinus,
(iii) to take a pre-operative CT scan to evaluate sinus anatomy and identify preexisting pathology,
(iv) a smoking cessation protocol is always recommended
and, especially in case of heavy smokers (≥15 cigarettes a day), evaluated with caution [26],
(v) preventive resolution of periodontal and endodontic
diseases,
(vi) adequate antibiotic prophylaxis,
(vii) to achieve full mouth plaque score (FMPS) and full
mouth bleeding score (FMB5) <15%. In case of provisional crowns it is advisable to remove the temporary crowns and disinfect the abutments with antiseptic solution,
(viii) preop disinfection of the skin with an antiseptic solution and mouth rinses with chlorhexidine,
(ix) use of sterile draping and infection-control protocol,
(x) to keep the incision distant from the antrostomy,
(xi) salivary-contamination prevention for bone graft
and/or other biomaterials,
(xii) intra- and postoperative control of the hemostasis,
(xiii) prevention of bone overheating,
(xiv) use of two different surgical sets of instruments: one
for the flap elevation phase and the other for the
grafting phase,
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International Journal of Dentistry
(xv) to rinse the surgical field with sterile saline solution,
(xvi) to keep the surgical time as short as possible,
[7]
(xvii) postoperative chlorhexidine rinses,
(xviii) correct postoperative pharmacological therapy,
(xix) preplanned patient controls: weekly for the first
month and monthly for the following 3 months.
[8]
4. Conclusion
The maxillary sinus elevation procedure using a lateral
window approach has been shown to be the most successful
bone augmentation procedure that is performed as a preprosthetic procedure before implant placement [5]. When
success is measured by patient outcome (success of the grafting procedure), the excellent result rate achieved is due to
the fact that complications are minimal and possibly further
on prevented through proper case selection, good surgical
technique, and proper and prompt handling of intraoperative and postoperative complications. Properly performed
sinus grafting does not alter neither sinus function [13] nor
the characteristics of the voice [25]. When measured by
implant outcome (implant survival rate), it has been shown
that implant survival rates in the high 90th percentile can
be achieved through proper decision making with regard to
implant surfaces (textured), graft materials (highest survival
with xenografts), and the placement of a barrier membrane
over the window. Complications are infrequent and those
that occur after sinus grafting procedures are for the most
part localized and readily resolved. Since prevention is better
than treatment, the clinical recommendations given by the
panel will help in reducing the incidence of the postop
infections.
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